Run Chart Audit for Depression Screening and Follow-Up Measure — Free

Audit Scope and Patient Eligibility

Patient is age 12 or older on the date of service critical (required)

Verify the patient met the age threshold for the measure on the encounter date.

Yes No N/A

Encounter falls within the audit period critical (required)

Confirm the charted encounter is within the reporting or review period selected for the audit.

Yes No N/A

Encounter type is eligible for depression screening review

Identify whether the visit type supports screening documentation review.

Depression Screening Documentation

Standardized depression screening tool documented critical (required)

Confirm the chart identifies a standardized depression screening instrument.

Screening result documented in the chart critical (required)

Result should be clearly visible in the note, flowsheet, or screening section.

Yes No N/A

Screening score or result is specific and interpretable

For example, PHQ-9 total score or a clearly stated negative/positive result.

Yes No N/A

Screening date matches the eligible encounter

Verify the screening was completed during the encounter or within the documented review window.

Yes No N/A

Positive Screen Follow-Up Plan

Screening was positive or indicates follow-up was required critical (required)

Use this item to determine whether follow-up documentation should be expected.

Follow-up plan documented for positive screen critical (required)

Examples include repeat assessment, referral, safety assessment, treatment plan, or scheduled follow-up.

Yes No N/A

Follow-up action is clinically specific

The plan should identify what will happen next, not just 'follow up as needed.'

Yes No N/A

Follow-up timeframe documented when indicated

If the chart indicates a timeframe, verify it is documented clearly (for example, within 30 days when required by the measure or local policy).

Yes No N/A

Referral or escalation documented when clinically indicated

Examples include behavioral health referral, crisis evaluation, or provider notification.

Yes No N/A

Documentation Quality and Measure Compliance

Documentation is complete and easy to locate

Screening and follow-up documentation should be readily identifiable in the chart.

No contradictory documentation is present

Check for conflicting notes, duplicate entries, or inconsistent results that would create ambiguity.

Yes No N/A

Audit finding

Overall audit determination based on screening documentation and follow-up requirements.

Note (optional)

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Run: Chart Audit for Depression Screening and Follow-Up Measure

Audit Scope and Patient Eligibility

Depression Screening Documentation

Positive Screen Follow-Up Plan

Documentation Quality and Measure Compliance

Get your results